The recent killing of a UnitedHealthcare executive has started a national dialog about the frustrations many patients, families, and doctors have when their health insurance company denies treatment, unfairly won’t authorize care, has unreasonable prior authorization rules and/or just plain refuses to pay legitimate claims.
These denials of care often, maybe even usually, happen during the most difficult times in a patient’s or family’s life. The national resonance has been palpable – probably because so many people have been denied care.
Thankfully, consumers have some protections because of federal laws like the Employee Retirement Income Security Act (for employer-sponsored plans) as well as under the Affordable Care Act for Marketplace plans. There are also some limited protections in state law.
When your claim is denied, health insurers must provide a detailed explanation of the denial, including references to the specific plan provisions on which the denial is based. Consumers also have the right to request their entire claim file, which includes all documents, records, and other information related to the denial.
Steps you can take when your insurance company denies a claim or doesn’t authorize payment for treatment:
Try to Understand the Denial
Review the explanation of benefits or denial letter from your insurer. Common reasons include errors, lack of preauthorization, or disputes over coverage.
Contact Your Insurer
Badger your insurer to clarify and address the denial. Sometimes, issues can be resolved with more documentation or corrections. Be a squeaky and bothersome wheel.
Ask Them for (demand) Your ‘Claim File’
A claim file is a collection of the information your insurer used to decide whether it would pay for your medical treatment or services. Claim files include internal correspondence, recordings of phone calls, case notes, medical records and other relevant information. Information in your claim file is critical if you end up needing to appeal your claim denial.
ProPublica’s Claim File Helper lets you customize a letter requesting the notes and documents your insurer used when deciding to deny you coverage. Get your claim file before submitting an appeal.
Claim File Helper: Request Your Claim File — ProPublica
File an Appeal
If you’re still having trouble you may need to file an appeal. Every insurer has a specific process for filing appeals, outlined in your policy or the denial letter:
- Write a formal appeal letter using info from your Claim File.
- Include supporting documentation (e.g., medical necessity letters from your doctor).
- Submit your appeal within the specified deadline (often only 30–180 days from the denial date).
The Affordable Care Act requires insurers to offer an internal appeals process if you have Marketplace plan. If denied again, you can request an external review by an independent third party. How to appeal an insurance company decision | HealthCare.gov has some information on that process.
Internal appeal: If your Marketplace Plan claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
External review: You have the right to take your Marketplace Plan appeal to an independent third party for review. This is called an external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
File a Complaint with ADIFI
You can also file a complaint with the Arizona Department of Insurance and Financial Institutions. They’re supposed to investigate claims and ensure insurers follow state regulations (which are not rigorous by the way). You can file your complaint. You can file your complaint with ADIFI here.
Dealing with a refused prior authorization, unreasonable prior auth requirements and denied claims is frustrating and even scary because it often comes at a really hard time in a person’s life. But… not giving up and advocating for yourself and your family with the strategies above might make a difference… and remember you might be able to dump your carrier during your next open enrollment.